Behavioural Activation for Depression
Behavioural activation (BA) is an integral part of CBT treatment for depression and here I intend to introduce what it is and why it is so effective. As you can see, the Behavioural Activation section is divided into multiple pages. This is because we will be looking at what I call “simple BA” and “analytical BA”. Please don’t get too hung up on these distinctions – ultimately BA is all about understanding the behavioural changes which occur during a depressive episode and modifying them to achieve some degree of recovery.
As this guide aims to give you the tools and skills to facilitate your own management of New Dad Depression symptoms in as easily accessible way as possible, I’m going to detail much of the science behind BA elsewhere on the site, getting stuck into how we apply it straight away.
Why is behaviour so important?
It is common within depression for an individual to experience changes in behaviour and reductions in activity levels. You may be experiencing this yourself at the moment. You know that you could go out for that walk or make that call to your family but nothing seems to be motivating you to do it. You procrastinate or avoid doing what was previously a simple, often enjoyable task. Why does this happen? Take a look at the illustration below:
The vicious circle of avoidance and reduced activity.
We can see here how being exposed to difficult life events leads to difficult negative emotions such as sadness, anger or anxiety. We will explore exactly how this process occurs in more detail when we start to look at the role of cognition, See our blog on Changing your Negative Thoughts , but for now it is important to stress that this is something that we all share – when life is difficult, we experience emotional distress.
Just like with physical pain, if I am exposed to something which causes me distress, it is a natural response for me to want to move away from it. For instance, if I put my hand on a hot stove, my natural reaction is to pull away. If I didn’t, then I would experience even greater pain and cause physical damage to my hand. Viewed in this light, pain serves the purpose of keeping me safe and preventing further injury. This is also true of emotional pain.
Evolutionary theories relating to depression suggest that negative emotions developed to serve the purpose of providing us with a signal to reduce further exposure to stressful life events. Just like with the hot stove, the sadness I feel when exposed to a particular stressor can be quickly relieved by pulling away from it. Of course, this is fine if it is just the one stressful event which I have to deal with, however, as you probably know first-hand, this is not always the case.
As we have already highlighted in Male PND , having a new baby on the scene can come with a huge amount of challenges, many of which can carry some degree of emotional distress. Having my sleep disturbed for the 3rd time tonight may make me feel the emotion of frustration. Being criticised for putting a nappy on wrong might make me feel sadness. Being pushed out of the way while the mother-in-law barges through may make me feel envy. None of these are pleasant emotions and it is a natural response for us to pull away and avoid the cause of the distress. As a short term solution this may work, however if the use of avoidance is our primary strategy to dealing with the multiple challenges which come with being a new dad, we may start to find ourselves avoiding causes more and more. I start sleeping on the couch to avoid the night feeds. I make excuses to avoid changing nappies. I lock myself away and pretend to work when my mother-in-law is coming to visit.
As a consequence of this spiral of avoidance, I now find myself doing less and less, isolating myself further and missing out on the potential positives of being a new dad. As I isolate myself, I find myself with more time to mull over and brood upon why I’m not able to cope with these challenges, making myself feel worse in the process. Without realising that my avoidance and reduced activity levels are actually feeding my depression, I’m already living a life of making excuses, isolating myself and minimising opportunities to experience life events which might actually lift my mood. As depression progresses, I may do less of the basic activities which I once found it easy to take care of. Getting showered, putting on clean clothes, staying in contact with family or friends are all typical behaviours which can fall by the wayside as a consequence of depression.
Getting started with behavioural activation.
So what do we do about this? Well, as the name might suggest, behavioural activation is the technique of activating the depressed individual to engage in activities which have fallen by the wayside. This is how we do it:
Step 1 – Setting a Baseline – What are your activity levels like this week?
The graphic below displays one of the main tools in behavioural activation for depression: The activity diary. You can download your own copy here Activity-diary-Acbt.
The Baseline diary can be an insightful way to find out just how our behaviour has changed.
A behaviour diary is used within CBT to both record current levels of activity and to schedule future activities which may be beneficial to alleviating your depression. Currently, we are going to use it to fulfil two functions:
1. To develop a baseline measurement of your current activity levels prior to engaging in any behavioural activation.
2. To identify specific activities which lift your mood.
HOW TO USE THE BEHAVIOUR DIARY:
Take a look at the diary and you’ll see how it breaks down into hourly sections, from 07:00 am until 12:00 am, for each of the 7 days of the week. What I’d like you to do is to record each activity you engage in for a one week period. By “activity”, I mean every behaviour you find yourself doing, from eating, walking and watching T.V. to staring out of the window, playing squash and having sex. Take a look at this example…
Use to the diary to record each activity you engage in over the week.
After a week of completing the diary, take a look at it. What do you notice? Are there any patterns of inactivity which emerge. Are there any situations or people which you avoid more than you realised. Did you do anything that you enjoyed? Often when people complete the baseline activity diary, they can be shocked by the patterns of inactivity, avoidance or lack of routine which have become a part of their lives. But I don’t want you to be put off by this. This is just a baseline, a starting point. Take this diary and put it somewhere safe for now as it will be a useful comparison as we are on our way to recovery.
Take a fresh activity diary and, again for one week, start to record the activities which you engage in on an hourly basis. This time however, we are going to add a little bit more information. For each of the activities, I would like you to answer the following two questions:
• How much pleasure did I feel whilst doing this activity?
• How much achievement did I feel whilst doing this activity?
What do I mean by pleasure?
Literally any positive feelings at all, even if it was the slightest emotional lift for just a few seconds. A walk in the park, a hug off your partner or playing with your child may give you more pleasure than, say, staying in bed for the day, or staring out of the window. I’d like you to rate pleasure on your diary on a 0 to 8 scale, with 8 representing the most pleasure you could possibly have from an activity, 0 representing none at all.
What do I mean by achievement?
This means any sense of mastery or pride in completing an activity. Based upon experience, this section often requires some degree of clarification. I’ve had clients return to me having scored some activities reasonably high in terms of pleasure, but failing to score anything in terms of achievement. Upon discussion regarding this, many assume that basic tasks such as shaving, preparing a meal or getting the baby dressed are “things I should be doing anyway” and as such do not merit any sense of achievement. This is an assumption which I challenge straightaway. The client is evaluating their achievements based upon how they would expect to be if they didn’t have depression, when the reality of the situation is that they do. The very fact that the individual is doing something which they would typically be avoiding due to their depression confers some degree of achievement, and this is what I would like you to remember when you are rating your activities for achievement. Rate them as you are TODAY, not as you think you should be. Again, rate the level of achievement experienced from each activity on the same 0 to 8 scale. Here’s an example of a completed diary with A (achievement) and P (pleasure) ratings included.
Activity diary with Pleasure and Achievement ratings included.
So now we should have two full weeks worth of data relating to what your activity levels are currently like, and how much pleasure and achievement you are taking from them. All sorts of useful information can come out of using the diary. For instance, we can see the areas of our life which actually do give us, even if just for a short time, an increase in positive experience. Likewise, we can also identify the activities which contribute very little to our sense of achievement or pleasure, such as the four hours of watching T.V. each night we might engage in. We can also see patterns in our behaviour more clearly. Sometimes people will notice that they are sleeping during the daytime more frequently than they thought, or notice that they are drinking alcohol throughout the week. The data that we get from using the baseline behaviour diary can be enlightening, useful and at times surprising, but if you use it as I’ve described, then the foundations of behavioural activation are set and we can progress to the next stage of your recovery.
Next, we are going to start activating – identifying the behaviours which give us the most positive uplift, or which tie in with our values, and schedule more of them in our lives.